NUR 104 MIDTERM EXAM-TEST QUESTIONS AND
ANSWERS| GUARANTEED PASS | LATEST EXAM UPDATE
2026/2027/2028 | EXAM PREP | STUDY GUIDE |
PRACTICE TEST
1. A nursing student is preparing to administer morning medications to an assigned adult
client diagnosed with hypertension. The client states, "I usually take a pink pill in the
morning, but I do not see it on this medication sheet." What is the most appropriate initial
action for the student to take?
A. Administer the prescribed medications as listed on the current medication administration
record.
B. Withhold all morning medications until the client's blood pressure is measured and
documented.
C. Compare the client's current medication administration record with the original provider
orders in the chart.
D. Explain to the client that prescriptions frequently change during hospital admission and
proceed with administration.
Answer: C
Comparing the medication administration record against the primary care provider's original
orders is the necessary safety standard to identify potential transcription discrepancies or
omitted prescriptions before administration.
2. A registered nurse is supervising a student nurse while inserting an indwelling urinary
catheter for an adult female client. Which action by the student requires immediate
intervention by the registered nurse?
A. Placing the sterile drape on the clean bedside table before opening the catheter kit.
B. Cleansing the labia minora using a new cotton ball for each stroke from front to back.
C. Maintaining the non-dominant hand as clean while using the dominant hand to handle sterile
equipment.
D. Inflating the retention balloon with sterile water immediately after feeling urine return in the
tubing.
Answer: A
Sterile drapes must be placed on a sterile field or properly managed surfaces; placing a sterile
item on a standard non-sterile bedside table contaminates the field and breaks sterile
technique.
,3. A community health nurse is conducting an educational workshop on hand hygiene for
healthcare workers in a long-term care facility. According to current guidelines, when is it
appropriate to use alcohol-based hand rub instead of soap and water?
A. When hands are visibly soiled with organic material or bodily fluids.
B. Before and after direct contact with each individual client when hands are not visibly soiled.
C. Immediately after caring for a client diagnosed with confirmed Clostridioides difficile
infection.
D. After removing non-sterile gloves that were worn during an invasive wound dressing change.
Answer: B
Alcohol-based hand rubs are the preferred method for routine hand hygiene in clinical
settings when hands are not visibly soiled, providing rapid antimicrobial action.
4. An adult client admitted with acute appendicitis reports sudden, severe relief of lower
right quadrant abdominal pain followed by generalized abdominal distension and rigidity.
What is the nurse's priority assessment and interpretation?
A. The appendicitis is resolving spontaneously, requiring continued routine vital signs
monitoring.
B. The client has developed bowel perforation and peritonitis, requiring immediate surgical
notification.
C. The client is experiencing opioid-induced constipation, necessitating an immediate laxative
order.
D. The appendix has shifted position, indicating a benign change in the inflammatory process.
Answer: B
Sudden cessation of pain in acute appendicitis often indicates rupture or perforation, leading
to peritonitis, which is a surgical emergency requiring immediate provider notification.
5. A charge nurse is evaluating a newly licensed nurse's understanding of standard
precautions. Which client interaction requires the nurse to wear a protective gown in
addition to gloves and a surgical mask?
A. Assisting a client with active tuberculosis with ambulation down the hallway.
B. Administering subcutaneous insulin to a client diagnosed with acute hepatitis B.
C. Providing routine hygiene care to a client with copious wound drainage that is not contained
by dressings.
D. Distributing lunch trays to a client diagnosed with uncomplicated seasonal influenza.
Answer: C
, Standard and contact precautions dictate that gowns must be worn when performing tasks
where contact with blood, body fluids, secretions, or excretions is anticipated or when wound
drainage is uncontained.
6. A nurse is assessing an older adult client who was admitted 48 hours ago following a hip
replacement surgery. The client appears restless, pulls at intravenous lines, and expresses
fear that unfamiliar hospital staff are plotting to harm them. How should the nurse
document and classify this acute behavioral change?
A. Progressive senile dementia associated with advanced chronological aging.
B. Acute delirium triggered by postoperative physiological stressors and environmental changes.
C. Major depressive disorder exacerbated by physical immobility and hospitalization.
D. Schizophrenia relapse secondary to cessation of outpatient antipsychotic medications.
Answer: B
Delirium is characterized by an acute, fluctuating onset of confusion, altered consciousness,
and perceptual disturbances, commonly triggered in older adults by surgery, infection, or
unfamiliar environments.
7. A nurse is planning care for an adult client with a stage 3 pressure injury on the sacrum.
Which intervention should be included in the interdisciplinary care plan to promote
optimal wound healing?
A. Cleanse the wound bed rigorously with hydrogen peroxide during every dressing change.
B. Massage the reddened skin surrounding the wound edges to stimulate peripheral blood flow.
C. Maintain a moist wound healing environment using hydrocolloid or absorbent dressings as
prescribed.
D. Expose the open wound bed directly to room air to facilitate rapid dry scabbing.
Answer: C
Maintaining a moist wound bed promotes epithelial cell migration, accelerates granulation
tissue formation, and prevents cellular dehydration, which is standard for pressure injury
management.
8. A home health nurse is assessing an older adult client's living environment for fall
hazards. Which finding poses the most immediate safety risk requiring correction?
A. Presence of low-pile wall-to-wall carpeting throughout the primary living areas.
B. Extension cords running underneath unsecured scatter rugs in the hallway.
C. Adequate illumination provided by 60-watt overhead incandescent lighting fixtures.
D. Grab bars securely anchored to the wall studs inside the shower stall.
Answer: B
ANSWERS| GUARANTEED PASS | LATEST EXAM UPDATE
2026/2027/2028 | EXAM PREP | STUDY GUIDE |
PRACTICE TEST
1. A nursing student is preparing to administer morning medications to an assigned adult
client diagnosed with hypertension. The client states, "I usually take a pink pill in the
morning, but I do not see it on this medication sheet." What is the most appropriate initial
action for the student to take?
A. Administer the prescribed medications as listed on the current medication administration
record.
B. Withhold all morning medications until the client's blood pressure is measured and
documented.
C. Compare the client's current medication administration record with the original provider
orders in the chart.
D. Explain to the client that prescriptions frequently change during hospital admission and
proceed with administration.
Answer: C
Comparing the medication administration record against the primary care provider's original
orders is the necessary safety standard to identify potential transcription discrepancies or
omitted prescriptions before administration.
2. A registered nurse is supervising a student nurse while inserting an indwelling urinary
catheter for an adult female client. Which action by the student requires immediate
intervention by the registered nurse?
A. Placing the sterile drape on the clean bedside table before opening the catheter kit.
B. Cleansing the labia minora using a new cotton ball for each stroke from front to back.
C. Maintaining the non-dominant hand as clean while using the dominant hand to handle sterile
equipment.
D. Inflating the retention balloon with sterile water immediately after feeling urine return in the
tubing.
Answer: A
Sterile drapes must be placed on a sterile field or properly managed surfaces; placing a sterile
item on a standard non-sterile bedside table contaminates the field and breaks sterile
technique.
,3. A community health nurse is conducting an educational workshop on hand hygiene for
healthcare workers in a long-term care facility. According to current guidelines, when is it
appropriate to use alcohol-based hand rub instead of soap and water?
A. When hands are visibly soiled with organic material or bodily fluids.
B. Before and after direct contact with each individual client when hands are not visibly soiled.
C. Immediately after caring for a client diagnosed with confirmed Clostridioides difficile
infection.
D. After removing non-sterile gloves that were worn during an invasive wound dressing change.
Answer: B
Alcohol-based hand rubs are the preferred method for routine hand hygiene in clinical
settings when hands are not visibly soiled, providing rapid antimicrobial action.
4. An adult client admitted with acute appendicitis reports sudden, severe relief of lower
right quadrant abdominal pain followed by generalized abdominal distension and rigidity.
What is the nurse's priority assessment and interpretation?
A. The appendicitis is resolving spontaneously, requiring continued routine vital signs
monitoring.
B. The client has developed bowel perforation and peritonitis, requiring immediate surgical
notification.
C. The client is experiencing opioid-induced constipation, necessitating an immediate laxative
order.
D. The appendix has shifted position, indicating a benign change in the inflammatory process.
Answer: B
Sudden cessation of pain in acute appendicitis often indicates rupture or perforation, leading
to peritonitis, which is a surgical emergency requiring immediate provider notification.
5. A charge nurse is evaluating a newly licensed nurse's understanding of standard
precautions. Which client interaction requires the nurse to wear a protective gown in
addition to gloves and a surgical mask?
A. Assisting a client with active tuberculosis with ambulation down the hallway.
B. Administering subcutaneous insulin to a client diagnosed with acute hepatitis B.
C. Providing routine hygiene care to a client with copious wound drainage that is not contained
by dressings.
D. Distributing lunch trays to a client diagnosed with uncomplicated seasonal influenza.
Answer: C
, Standard and contact precautions dictate that gowns must be worn when performing tasks
where contact with blood, body fluids, secretions, or excretions is anticipated or when wound
drainage is uncontained.
6. A nurse is assessing an older adult client who was admitted 48 hours ago following a hip
replacement surgery. The client appears restless, pulls at intravenous lines, and expresses
fear that unfamiliar hospital staff are plotting to harm them. How should the nurse
document and classify this acute behavioral change?
A. Progressive senile dementia associated with advanced chronological aging.
B. Acute delirium triggered by postoperative physiological stressors and environmental changes.
C. Major depressive disorder exacerbated by physical immobility and hospitalization.
D. Schizophrenia relapse secondary to cessation of outpatient antipsychotic medications.
Answer: B
Delirium is characterized by an acute, fluctuating onset of confusion, altered consciousness,
and perceptual disturbances, commonly triggered in older adults by surgery, infection, or
unfamiliar environments.
7. A nurse is planning care for an adult client with a stage 3 pressure injury on the sacrum.
Which intervention should be included in the interdisciplinary care plan to promote
optimal wound healing?
A. Cleanse the wound bed rigorously with hydrogen peroxide during every dressing change.
B. Massage the reddened skin surrounding the wound edges to stimulate peripheral blood flow.
C. Maintain a moist wound healing environment using hydrocolloid or absorbent dressings as
prescribed.
D. Expose the open wound bed directly to room air to facilitate rapid dry scabbing.
Answer: C
Maintaining a moist wound bed promotes epithelial cell migration, accelerates granulation
tissue formation, and prevents cellular dehydration, which is standard for pressure injury
management.
8. A home health nurse is assessing an older adult client's living environment for fall
hazards. Which finding poses the most immediate safety risk requiring correction?
A. Presence of low-pile wall-to-wall carpeting throughout the primary living areas.
B. Extension cords running underneath unsecured scatter rugs in the hallway.
C. Adequate illumination provided by 60-watt overhead incandescent lighting fixtures.
D. Grab bars securely anchored to the wall studs inside the shower stall.
Answer: B
